If you would prefer to take this information in through video presentation, please refer to the free webinar I did on this same topic.
“The rooster can take credit for the sunrise but that doesn’t make it so” – My dad, paraphrased from someone else, probably
Feeling better is frequently used as a measure of success in the training, pain/rehab, and medical world. First, there is an onset of pain or symptoms start to occur, either acutely in an identifiable event (dropped a barbell on your toe, low back pain during a heavy deadlift, rolled ankle, etc.), or insidiously aka slowly over time without a notable event. There might be an intervention applied to the body area specifically or generally, aimed at alleviating these pains or symptoms, or not. Finally, the pain or symptoms dissipate, the person feels better and then returns back to the baseline, ideally. This is the typical formula seen in the medical field as well as outside of the medical field.
The study of suitable interventions for various symptoms is constant and always being updated within the medical field so providers and scientists alike do not unknowingly fall victim to some of the things that are going to be expanded on in this article. The difference between the medical field and the general population is that there is an understanding that there exists a disconnect between A and B equalling C, due to the immense complexities of the human organism. Unfortunately due to the complexities of not only the human organism but also the topic of pain itself and also the topic of “feeling better” sometimes there too exists this disconnect within the medical field. Well, as long as the person gets better, what’s the big deal? Right?
Nature Always Wins
There are two things that play hand in hand when it comes to pain events or things that are out of the ordinary. The first is natural history or the tendency for symptoms to just get better over time due to the ability of the human organism to heal. This is seen more convincingly in acute events like getting cut or hitting your thumb with a hammer. Whether or not you received any sort of intervention in response to these events, your natural tendency is to heal and return to homeostasis, or your equilibrium. The second is a bit more complicated and is seen in the statistical world. It’s called regression to the mean, and it basically says that extremes level out over time. Your flare-up of low back pain is outside of your baseline or your normal distribution of body status and is unlikely to stay at that level for a long time. There is room to say that “it depends” on how long a long time is, but let’s not get caught up in minutia.
Regression to the mean and natural history can be seen increasing the size of the provider’s egos in the following scenario. You, for some reason unknown to you or anyone, have an onset of shoulder pain. This shoulder pain is outside of your normal, enough to cause an action on your part in the form of reaching out to a clinician/provider/coach for assistance. The authority figure of your choosing evaluates you, makes a decision for intervention (dry needling, manipulation, hitting you aimlessly with a hammer and chisel), and sends you on your way. Over the few days to couple weeks, you start to feel much better and see that things are going to be ok! Upon your return to your provider, you tell them the good news and what do they say? “I’m so glad my intervention gave you relief!” Whether or not this is the case is debatable, and introduces us to our next topic of discussion: the post hoc fallacy.
Post Hoc Ergo Propter Hoc
Post hoc ergo propter hoc, or more commonly referred to as post hoc, is a logical fallacy in which one event is said to be the cause of a later event simply because it occurred earlier. In relation to the above context, we can see how relating an improvement in patient/client status to the intervention provided can be wrongfully done. Both the patient and person administering the intervention, if unaware of this logical fallacy can give undue weight to the intervention that predated the improvement in patient/client status and then may be more likely to apply this to others or recommend it to others. This can pose an issue if the intervention is not based on science/evidence or if it is something that could open the patient/client up to harm (injections, needling, rest, surgery, etc.).
Context is always at work, dictating how you act, think, interact with your environment, how you feel, and how you perceive. Context includes:
- the style of office you’re sitting in
- the temperature of that office
- the art on the walls
- the degrees on the walls
- the music playing
- the type of equipment in the clinic
- the attire of your provider
- the title of your provider
- the type of interventions they provide (hands-on, invasive, education only, shared decision making, top-down, etc.)
- how you’re feeling that day
- what you’ve heard about this provider
- if they are new to you
- past experiences you’ve had with this pain event/provider/clinic/healthcare system
- the knowledge you have about what’s currently going on
The list is long regarding things that have an effect on you, and it really is quite interesting how all of these factors can play into how your session with your provider/coach goes. If you’re in a familiar place with a provider/coach that you’ve heard great things about or trust, if the temperature in the office feels comfortable, if you had a good interaction with the front desk staff, then the following appointments that you have with the provider/coach are likely to go well. If you’re going to a new place with 3.5/5 stars on google and one review that says that provider/coach is an asshole, it’s snowing out and you hate the snow, the front desk staff doesn’t look you in the eye and there isn’t anywhere left to sit in the waiting room, its likely not going to go as well in the office as it would if conditions were better.
Expectations and Beliefs
While all of the topics that are going to be discussed here play closely with one another, one of them is better discussed within the context of contextual effects, and that is expectation. Some of this might seem redundant and it is. It is all intertwined with one another and that’s the point here. Now about expectation.
Expectation can and does influence our perception of the world. The past experiences and learned responses of someone can influence their perception of what a physical therapist might be able to do for them, whether that be good or bad. That past experience might come from the story of a close relative and how much they had their low back pain helped from a physical therapist. That past experience might also lack to exist if they have never gone to physical therapy, and only massage therapy. The beliefs that someone has accrued will, on some level, dictate how powerful of an interaction that person has when exposed to something new, whether that be good powerful, or bad powerful. Think of it as a self-fulfilling prophecy. Someone presents you with a box that has air holes in it and that you cannot see into and tells you to stick your hand in. You might intuit from the holes in it and your experience growing up with a bunch of gerbils that there might be an animal in there. Despite the fact that there is only a potato in the box, you are cautious not to crush whatever is in the box, or not to get bitten by it. This is similar to how expectations and beliefs play into outcomes.(internal link to expectations article)
While it is generally of good form to be polite to those who are trying to help you, like providers/coaches trying to help guide patients/clients towards symptomatic relief, politeness can muddy up feedback regarding success or failure of care. You as a patient/client are trying your best to follow direction and get better so that you can return to your provider/coach with the good news that their stuff gave you relief! Everyone wins in that world! Unfortunately, there are frequently times that people don’t get better with what you give them, and it feels bad for everyone. This is where politeness can get in the way because, in an attempt to get to that win-win world, patients/clients can and do lie about how well they are doing. They say that it’s a 3 instead of a 7 now or that they can get out of bed easier than before. While these may be white lies, it has the ability to reinforce the thought that a certain intervention or treatment method holds more weight than it should, likely increasing the chances that this possibly useless intervention gets used again.
Polite patients can also influence our next effector of outcomes which is recall bias. Recall bias is a systematic error that occurs when participants do not remember previous events or experiences accurately. If we take our polite patient, our post hoc fallacy, natural history, and regression to the mean, all of these together can aid in creating a skewed memory of what has worked in the past and what hasn’t. When a patient/client comes back with a really great improvement or accomplishes something, it’s easy to remember that. While its also easy to remember what made things much worse, it’s unlikely that those interventions would be applied again in the future. On the other side of the coin, if we get a few polite patients that fall under similar categories of treatment or a few clients that experience similar regression to the mean/natural history, the intervention provided to those people has the ability to stand out because it seemingly has given great returns, because everyone is saying that they are feeling much better.
This plays tightly into survivorship bias which is a way for current information to be skewed due to there being a limitation of all of the information from making it to you. In the context of this article, we can think about survivorship bias being represented in those people who don’t come back for more services after an interaction. A running joke in the PT world, or at least the one that I’ve existed in, is that if someone doesn’t come back after 1 or a few sessions it is because they must have gotten better. I mean, they certainly couldn’t have gotten worse, right? The truth is that unless we reach out and ask them, we will never know, and this is information that does not make it back to us. While it is possible that those people are fully better and no longer need our services, it is also possible that those people either didn’t like their provider, the clinic, or the intervention and decided not to come back, which biases the population that does come back because they are seeing positive benefit from intervention. This can make providers/coaches think that they have that one weird trick that gets everyone better because everyone utilizing their services is getting better. They fail to realize that those who weren’t didn’t come back.
The scientific method is our best attempt at removing this inherent bias from the equation when trying to figure out complex systems such as the human organism. Its main tenant is the ability to control situations because as we have seen from this article, there are many variables that can confound or make fuzzy our interpretation of what is going on. With science, we are able to compare groups, one group receiving the intervention, and the other receiving nothing, and see if there is a difference or not. We can then examine the presence or lack of a difference and see if it was due to the mechanism of that specific intervention or not. If that intervention played some specific part in the change, fantastic! Maybe we should look harder at that intervention and continue to control for bias and alternate variables. If that intervention did not play some specific part in the change, then that is also information, maybe more so on outside variables.
What Does This All Mean?
The goal of this article is to highlight that in regard to subjective outcomes, or how someone is reporting they are feeling, there is much at play. The intention of a clinician is to utilize interventions due to their understanding of what exactly that intervention is accomplishing on a physiologic level which can very much so be muddied up by all of the things discussed here. Inappropriate weight can be placed into an intervention by those unaware of all of the factors involved and that intervention can lead both the provider and patient down a harmful rabbit hole of inaccurate narratives and poor causal theories. The reason why it matters regarding the why of someone feeling better is because if we understand the ability for the human organism to improve subjectively, then we need to understand that frequently, symptoms and people improve on their own. Exposure to the medical system is something that needs to be done carefully as there is harm that can occur in the form of overmedicalization, kinesiophobia, and nocebo effects, to name a few.